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NPI Code Detail

MEDICARE: WILLIE SANDOVAL LPC

MEDICARE: WILLIE SANDOVAL LPC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional Counselor12739TX

General Provider Information

NPI Number : 1063576882
Entity Type Code : Individual
Provider Name (Legal Business Name) : WILLIE SANDOVAL LPC
Provider Business Mailing Address
First Line : PO BOX 166821
Second Line :
City : IRVING
State : TX
Zip : 75016-6821
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2121 N MAIN ST
Second Line :
City : FORT WORTH
State : TX
Zip : 76106-8588
Country : US
Telephone Number : 817-320-3742
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/20/2006
Last Update Date : 07/08/2007

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